目的 探讨内镜逆行胰胆管造影(ERCP)检查及内镜治疗在腹腔镜胆囊切除(LC)术前、术后的应用价值。 方法 对61例拟行LC的患者术前或术后行ERCP检查，发现异常再行内镜治疗。结果 LC术前行ERCP者42例中39例显影，其中37例伴有其他胆管疾病，占94.9%。术后行ERCP者19例均显影，总的插管成功率为95.1%。LC术前或术后42例行EST治疗，4例行EPBD，2例行ERBD，15例行ENBD，另4例在行ERCP检查后改开腹手术，取石成功率为92.9%。结论 诊治性ERCP在LC前、后的应用，对进一步明确诊断、选择手术方式、预防LC的并发症和提高LC的成功率具有重要价值。
Objective To explore and summarize the application of minimally invasive technique to every stage of severe acute pancreatitis (SAP). Methods The treatment of 101 SAP patients admitted to our hospital between January 1995 and December 2008 were retrospectively analyzed. After calculi were removed by endoscopic retrograde cholangiopancreatograpy (ERCP) and endoscopic sphincterotomy (EST), endoscopic nasobiliary drainage (ENBD) were applied, then rhubarb liquid was perfused into gut with a nutrient canal and ultrasound-guided abdominal drainage tube were simultaneously placed at the early stage. Some patients received continuous renal replacement therapy (CRRT) at the same time. Laparoscopic cholecystectomy (LC) was performed at the subacute stage, and choledochoscope was introduced to remove parapancreatic necrotic tissues at the late stage of SAP.Results Of all the 101 cases treated by the method mentioned above, 75 cases received ERCP (or EST) and ENBD, and 31 cases underwent rhubarb liquid perfusion with a nutrient canal. Eight cases underwent continuous renal replacement therapy (CRRT). Forty-eight cases underwent LC and ultrasoundguided abdominal drainage. Thirtysix cases with infected peripancreatic tissue or abscess underwent debridement under choledochoscope 3 to 14 times at the later stage. Five cases died of multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS). The hemobilia ocurred in 2 patients during choledochoscopy and was cured under direct visualization by electric coagulation. Intestinal fistula happened in 3 cases and cured by drainage. Pancreatic pseudocyst was latterly seen in 3 cases and treated by the anastomosis of cyst with jejunum through selective operation. After the hospitalization of 9-132 d (mean 24 d), 96 cases completely recovered. Conclusion Timely application of minimally invasive technique to every stage of SAP can avoid the defects of traditional operations, decrease the injury and interference to the maximum, and raise the cure rate.
Objective To compare the difference in efficacy of early precut of pancreatic duct sphincter and pancreatic duct stent placement in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) during high-risk patients. Methods A prospective study was conducted on 61 eligible patients who underwent ERCP treatment in Department of Hepatobiliary Surgery of The First Affiliated Hospital of Xi’an Jiaotong University and Xianyang Hospital of Yan’an University, from November 2016 to November 2017. All cases were randomly divided into early pancreatic sphincterotomy group (n=30) and pancreatic duct stenting group (n=31) . The success rate of intubation, intubation, and incidence of complication were compared. Results There was no significant difference in the success rate of the first intubation between the 2 groups (P=0.580), but the intubation time of the early pancreatic sphincterotomy group was shorter than that of the pancreatic duct stenting group (P=0.007). In the early pancreatic sphincterotomy group, there was 1 case of post-ERCP pancreatitis, 1 case of biliary tract infection, and 1 case of postoperative bleeding. In the pancreatic duct stenting group, there was 1 case of post-ERCP pancreatitis, and 2 cases of biliary tract infection. No severe complications such as perforation or severe acute pancreatitis occurred in both 2 groups. There was no significant difference in the incidence of total complications and specified complication (included post-ERCP pancreatitis, biliary tract infection, and postoperative bleeding) between the 2 groups (P>0.05). Conclusions Thereis no significant difference in the incidence of postoperative pancreatitis after early precut of pancreatic duct sphincter and pancreatic duct stenting placement in patients with high-risk, but intubation time of early precut of pancreatic duct sphincter method is shorter than the pancreatic duct stenting placement method.
Objective?To assess the effectiveness and safety of diclofenac, one of the routine-used NSAIDs, in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). Methods Firstly, the electronic searches were conducted to retrieve Randomized controlled trials (RCTs) from The Cochrane Library, PubMed, Embase, OVID, CBM, CNKI, VIP and WanFang Data. Secondly, 12 kinds of specific Chinese journals like Chinese Journal of Gastroenterology and conference proceedings were hand-searched till June 2011, and all references in all included trials were searched, too. The RCTs on diclofenac for preventing PEP were identified and retrieved. The systematic review was conducted by using methods and principles recommended by the Cochrane Collaboration. Results A total of 5 RCTs involving 675 PEP patients were included. The Meta-analysis showed that diclofenac might reduce the incidence of PEP (OR=0.41, 95%CI 0.18 to 0.95, P=0.04), but the sensitivity analysis indicated this result was not stable. No evidence showed diclofenac could reduce the incidence of severe PEP (OR=0.40, 95%CI 0.08 to 2.06, P=0.27). And no adverse reactions related to the drug were reported. Conclusion Diclofenac may be safe and effective in reducing the incidence of PEP, but it has no significant effect on preventing severe PEP. Considering the methodological and scale limitation of included studies, this conclusion still needs to be proved by more large-scale and high-quality RCTs.
Pancreatic duct stones are secondary to chronic pancreatitis while conventional medical treatment is always not effective. Due to the advantages of less trauma, simple operation, and fewer complications, since endoscopic retrograde cholangiopancreatography (ERCP) combined with extracorporeal shock wave lithotripsy (ESWL) was first used in the treatment of pancreatic duct stones in 1987, the treatment method has been continuously improved for more than 30 years, and has experienced the development process from being questioned to becoming the first-line treatment for pancreatic duct stones in multinational guidelines nowadays. However, with the rapid development of science and technology today, the method of ERCP combined with extracorporeal lithotripsy is also facing the challenges of many other treatment methods.
Objective To discuss the value of biliary stent in treatment of malignant biliary obstruction with different pathways of bile duct stent insertion. Methods Fourty-two cases of malignant biliary obstruction whose biliary stent insertions were through operation (n=18), PTCD (n=17) and ERCP (n=7) respectively were reviewed retrospectively. Results The bile duct stents were successfully inserted in all patients through the malignant obstruction and achieved internal biliary drainage. Compared with the level of the bilirubin before operation, it decreased about 100 μmol/L one week after the stent insertion in all patients. Compared with the levels of glutamic oxalacetic transaminase, glutamic pyruvic transaminase, alkaline phosphatase and glutamyltranspeptidase before operation, they decreased 1 week after the stent insertion （Plt;0.05). The median survival time was 22 weeks. The average survival time was (32.89±33.87) weeks. Two patients died in hospital after PTCD, and the mortality was 4.76%. Complications included 8 cases of cholangitis, 3 cases of bile duct hemorrhage and 2 cases of hepatic failure. Conclusion The bile duct stent insertions through operation, PTCD and ERCP are all effective in relieving the bile duct construction with malignant biliary obstruction. Each method should be chosed according to the systemic and local condition for every patient so as to improve the safety and efficiency, and to decrease the occurrence of complications.
Objective To find the most effective treatment for a patient with difficult selective biliary cannulation (DSBC) during endoscopic retrograde cholangiopancreatography (ERCP) by EBM practice. Methods Evidence was retrieved from The Cochrane Library (Issue 1, 2010), ACP online, NGC (1998 to June 2010), PubMed (1950 to June 2010), and CBM (1994 to June 2010). The collected evidence was then graded. Results After preliminary research, we identified 18 relevant articles. The evidence showed that pre-cutting technique could increase cannulation success rates in DSBC and was safe, effective, and time-saving for an experienced endoscopist. Pancreatic duct occupation was easier to perform than pre-cutting technique and could also increase selective cannulation success rates in DSBC. According to the evidence, together with endoscopist’s experience and the preference of the patient and his family, needle-knife precut papillotomy was performed. Successful selective biliary cannulation was accomplished after pre-cutting. Conclusion The current evidence suggests that pre-cutting technique and pancreatic duct occupation could increase selective cannulation success rates in DSBC. Patients’ condition and endoscopist’s experience should be considered properly before the operation.
Endoscopic treatment of extrahepatic bile duct stones has become very common, but endoscopic treatment of intrahepatic bile duct stones for various reasons faces many difficulties and challenges. With the birth of new equipment and the advancement of technology, endoscopic treatment of intrahepatic bile duct stones has ushered in new opportunities, including peroral cholangioscopic technology and endoscopic ultrasonography, which have shown good application prospects. It will become an indispensable and important part in the treatment of intrahepatic bile duct stones.
Objective To evaluate the effectiveness and safety of pancreatic duct stenting in prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis for patients at high risk. Methods We searched the Controlled Trials Database of the Cochrane Upper Gastro-Intestinal and Pancreatic Disease Group (Issue 1, 2004), Cochrane Controlled Trials Register (Issue 1, 2004), MEDLINE (1966-2004, 4), EMBASE (1985-2004, 4), CBMdisk (1970-2004, 4), and the Chinese Cochrane Center Database of Clinical Trials; we handsearched 8 Chinese journals, and references of eligible studies were also screened for inclusion. Randomized controlled trials on pancreatic stent for preventing post-endoscopic restrograde cholangiopancreatography pancreatitis (PEP) were identified.The systematic review was conducted using methods recommended by the Cochrane Collaboration. Results Six trials involving 468 high-risk patients for post-ERCP pancreatitis were included. The incidence of post-ERCP pancreatitis was significantly reduced by pancreatic duct stenting (Peto RR 0.31, 95% CI 0.19 to 0.52; P＜0.000 01; NNT=6). The incidence of severe PEP was also significantly lower in pancreatic duct stenting group compared with the control group (Peto OR 0.13, 95% CI 0.04 to 0.47; P=0.002; NNT=24). The results were consistent with the sensitivity-analysis when abstracts were excluded. Conclusion Pancreatic duct stenting appears to be an effective method to prevent PEP. Due to the limitation of the included trials and their methodology, the results should be considered with caution. High quality and large-scale trials are required.